Written Evidence Submitted by Sam Hilton, Centre for the Study of Existential Risk

(CLL0092)

A. Background

 

  1. This paper is written by Sam Hilton, a Research Affiliate at the Centre for the Study of Existential Risk at the University of Cambridge.

 

  1. This paper addresses the Committees’ investigation into the issue of “the UK’s prior preparedness for a pandemic”

 

  1. This paper is based on a series of research interviews carried out with civil servants in 2019-20 on long-term policy making and risk preparedness and based on the author’s recent paper: Risk management in the UK: What can we learn from COVID-19 and are we prepared for the next disaster? [1], which provides more detail on a number of the topics mentioned in this paper.

 

 

B. Summary

 

  1. The UK prepared for a specific pandemic influenza scenario but did not prepare significantly for other pandemic scenarios. The UK’s National Risk Register (NRR) identified influenza as the most likely cause of a major pandemic in the UK [2] and highlighted a specific influenza scenario based on what would be “challenging” yet “reasonable for the NHS to plan for” [3]. The NRR underestimated the risks of non-influenza pandemics for example stating that “emerging infectious diseases” could lead to “several thousand people experiencing symptoms, potentially leading to up to 100 fatalities” [2]. The Department of Health focused pandemic preparedness plans on the specific influenza scenario identified.

 

  1. The Departments of Health’s pandemic influenza strategy was a fixed strategy with very limited options. For example the pandemic influenza strategy had no discussion of lockdowns and minimal discussion of other methods to reduce the R number, except for “possible school closures” and isolating the ill [4] yet in contrast, lockdowns have been the dominant strategy adopted by developed countries to counter the COVID-19 pandemic. A well designed flexible strategy should have raised the possibility of lockdowns as a possible plan.

 

  1. This paper firstly explains why the UK only identified influenza risks, see Section C. The paper then explains why the pandemic preparedness strategy was so rigid, see Section D. The reasons are complex but ultimately they come down to a flawed risk assessment process, an inability within government to handle uncertainty, and decision makers not having the incentives in place to prepare sufficiently for future risks. Section E sums this up and suggests recommendations the Committee could give to the government.

 

 

C. Why did the UK focus on influenza?

 

  1. The UK has risk management processes in place that aim to identify risks, to ensure that plans are drawn up to mitigate and prepare for disasters and to prevent risks being overlooked despite short term pressures. The UK’s National Security Risk Assessment (NSRA) takes place every other year and maps out all domestic, international, malicious and non-malicious risks. The drafting process is led by the Civil Contingencies Secretariat (CCS), which sits within the Cabinet Office and each risk is owned by a relevant government department [5][6]. Risks are represented by “reasonable worst case scenarios” (RWCS) that provide a “challenging yet plausible manifestation of the risk” [7]. A public version of the NSRA is known as the National Risk Register (NRR).

 

 

The NRR estimate of “up to 100” fatalities

 

  1. The most recent NRR (2017) set out in a concise manner a broad range of risks that could impact the UK. It did highlight the risk of an influenza pandemic, listing it as the biggest non-malicious risk to the UK. However, the risks from emerging infectious diseases beyond influenza were significantly underestimated.

 

  1. Looking back at this in the light of COVID-19, it is notable that the NRR stated that “emerging infectious diseases” could lead to “up to 100 fatalities” [2]. This estimate was very far from the mark and as such deserves some analysis and explanation.

 

  1. According to our interviews, this estimate was considered by civil servants to be a justifiable estimate of non-influenza infectious disease risks. Yet this was clearly out of line with the evidence available at the time. Academic papers available in 2017 raised the risk of a global outbreak due to emerging infectious diseases of all types [8][9]. Other assessments of global risks highlighted that non-influenza pandemics could kill millions [10][11]. There appears to have been a widespread view across academia that a SARS type pandemic could very easily have gone global [12] and that there was a reasonable probability of an emerging disease killing one billion or more people globally [13].

 

  1. Coronavirus is not influenza and it appears that the narrow focus on influenza was detrimental to government preparedness. For example, the government stockpiled the Personal Protective Equipment (PPE) needed for influenza but did not have sufficient gowns or visors for preventing COVID-19 transmission [14]. Similarly, the UK had well-rehearsed plans to develop an influenza vaccine within six months [2], but these could not be applied to COVID-19 [15].

 

  1. There are a number of steps that appear to have gone wrong to cause this. Below we highlight seven reasons why the UK risks assessment processes may have overly highlighted influenza compared to other pandemic risks:

 

 

Explanation for the focus on influenza

 

  1. There is a tendency to “prepare to fight the last war”. Planners tend to assume that the future will have many of the same features as the past, yet future risks often differ significantly from past risks. This is a known issue in defence and risk management, and was raised by civil servants we interviewed. An influenza pandemic has topped lists of UK concerns since swine flu in 2009, and the UK prepared for influenza rather than a coronavirus (or for a pandemic more broadly). Meanwhile countries that had experienced outbreaks of SARS (a coronavirus) in the early 2000s had better plans to handle COVID-19 [16][17][18].

 

  1. Pandemic estimates were based on events in the relatively recent past, notably Spanish flu in 1918, SARS in 2002, and Ebola in 2013 [19]. CCS did not consider historical events (such as Cholera pandemics in the 1800s or various plague epidemics). Looking at past events is often a useful approach for evaluating risks but high uncertainty risks, emerging risks or particularly large-scale risks should not be evaluated this way as their unfamiliarity means that the recent past will not be applicable. Furthermore, in focusing on the recent past the NSRA often ignores relevant historical data.

 

  1. The NSRA process does not fairly consider high uncertainty risks, such as novel diseases, like COVID-19. The NSRA only lists risks that are more likely than their threshold of 1 in 100,000 year scenarios. However, this threshold approach rests on the assumption that a reasonably accurate estimate of likelihood can be generated. For high-uncertainty risks this is not the case. This threshold approach forces risk assessors to exclude risks based on highly speculative estimates of likelihood.

 

  1. The way risks were delineated and categorised was flawed. The risk of a mass infectious disease was explicitly linked to influenza. (See the Annex below for an example of how risks could have been categorised better.)

 

  1. The Reasonable Worst Case Scenarios (RWCS) for pandemics were developed to be scenarios that were “reasonable for the NHS to plan for” [3]. The RWCS are designed as scenarios that would be a challenge for government to respond to yet reasonable to expect government to prepare for [7][3]. As such, they are not based solely on the nature of the risks but incorporate policy assumptions regarding what is expected of government. This is problematic because the NSRA treats these RWCS as if they were objective measures of risk, using them for mapping the scale of risks, comparing risks, and generating planning assumptions. Using these RWCS in these ways leads to incorrect conclusions and is misleading to policy makers. Furthermore it is not made clear to readers of the NRR (and maybe also to readers of the NSRA) that these scenarios are developed in this way.

 

  1. It is possible that academic research with contrary information was not given due consideration and relevant academics were not consulted. Although the CCS engages relevant experts both within and outside government as part of the NSRA process, academic risk experts have expressed concern that their voices are not sufficiently heard.

 

  1. It is possible that risks estimates were influenced by government departments deliberately over- or under-playing specific risks to affect their prioritisation. This concern was raised in the 2019 Parliamentary Office of Science and Technology report on risk assessment [6] and similar comments were made by those we interviewed.

 

 

Section conclusion

 

  1. None of the points above are specific to pandemic risks but are features of how the NSRA processes evaluate all types of risks. Furthermore this is not the first-time the NSRA processes has failed to sufficiently prepare the UK, for example, the risk from volcanic ash was only added to the NRA in 2012 after the 2010 and 2011 Icelandic eruptions [20], despite the availability of significant historical evidence from the 1700s that suggested such an event was highly probable [21][22].

 

  1. While no risk assessments are perfect in hindsight, we conclude that the estimate of an “emerging infectious disease” causing “up to 100 fatalities” was not a one-off bug or mistake but an inevitable feature of the current system, which has inherent design flaws. As such, it is quite possible that the UK risk assessment process has missed other risks.

 


D. The quality of the UK’s pandemic influenza strategy

 

  1. Given the UK government’s prioritisation of influenza, it drew up a number of plans between 2011 and 2014 for responding to this risk, including the 2011 Influenza Pandemic Preparedness Strategy. This plan was detailed, drew on the available evidence and considered the impact of an influenza pandemic on all sections of society.

 

 

Pandemic plans that did not have a lockdown option

 

  1. Although COVID-19 is not pandemic influenza, there are important similarities. In particular, the transmission pathways (including the possibility of aerosol and droplet transition and asymptomatic transmission) [23][24] and fatality rates [25] of the diseases are similar. We would thus expect the UK’s influenza strategy to be somewhat applicable to preventing the transmission of COVID-19.

 

  1. The UK’s pandemic influenza strategy had no discussion of lockdown or other methods to reduce the R number, except for “possible school closures” and isolating the ill. Instead, they aimed for a herd immunity-type approach, “supporting the continuation of everyday activities as far as practicable” and recommended no restrictions on international travel or public gatherings [4]. However lockdowns have been a dominant strategy followed by the UK and most other developed countries to respond to COVID-19. Not developing plans with a variety of options, including a lockdown option, appears to be a significant shortcoming of the influenza pandemic strategy. [26]

 

  1. There were other problems with influenza plans as well. For example instead of stockpiling PPE the government put in place “just in time” contracts with foreign manufacturers that then did not work as planned due to the global need for PPE.[27]

 

  1. Below we highlight three reasons why the UK’s pandemic influenza strategy may have lacked a variety of options for planners to follow:

 

 

Explanation for limited options in the UK’s pandemic influenza strategy

 

  1. There was a lack of expertise in planning for situations of high uncertainty. A flexible, adaptable plan that accounted for high uncertainty would have mapped out a broader range of strategies [28], and might even have partially mitigated the NSRA’s over-focus on influenza.

 

  1. There was a lack of systems thinking and speculative political thinking. A systems thinking approach might have identified a lockdown strategy as politically desirable and developed plans for it accordingly. Similarly, a former US Pentagon official reported that the Pentagon under-prepared for the politicisation of decision making involving the COVID-19 response [29].

 

  1. The plans were not regularly updated. For example, although the Department of Health reviewed the evidence on restricting gatherings in 2014 and stated that “restrictions of mass gatherings can reduce transmission” [30], no changes were made to the pandemic strategy based on this evidence. It is unclear if sufficient steps were taken to consider updating the strategy. Similarly, in 2016 the government carried out a simulation exercise of a flu outbreak, Exercise Cygnus, but the findings were not fully integrated into government plans [14].

 

 

Section conclusion

 

  1. This analysis suggests that UK political leaders inherited plans that were not well suited to the COVID-19 situation. This tallies with the criticism that has been levelled at the government that it initially responded slowly to the pandemic [31][32][33]. While, with hindsight, some problems with risk plans are always to be expected, more oversight of and support for risk planning would be advantageous to ensure the UK is better prepared for future disasters.

 

 

E. Underlying causes and recommendations

 

  1. It is challenging for the government to prepare for and to manage situations of high uncertainty. This trend cuts across many of the points raised in sections C and D above. Improving the expertise and support available for civil servants and Ministers working with situations of high uncertainty is vital for ensuring the UK is prepared for future risks.

 

  1. Civil servants interviewed identified political and civil service short-termism as underlying causes of poor risk management. They highlighted that where there had been more long-term practices in place, such practices had been eroded in part due to a lack of political or civil servant interest in long-term risk management. For example, when discussing the UK’s shift from a five year to a two year NSRA one civil servant said “there were some discussions around how useful people found the longer-term view of risk. When people look at risk they’re often looking at much more certain, or higher-probability, higher-impact risks.”

 

  1. Ultimately this means there is a need for a better governance structure to oversee and support good depoliticised expert-driven risk assessments. Improving the process for managing the NSRA and ensuring there is expertise to support government risk planners is important but is unlikely to be sufficient to ensure the UK is better prepared for future risks.

 

  1. Drawing on the evidence above and on best practice in private sector risk management and public sector governance approaches [1], we suggest the committee makes the following recommendations:

 

 

Recommendations

 

  1. RECOMMENDATION 1:

In learning the lessons from COVID-19, the government must not focus solely on risks similar to COVID-19, as the next catastrophe may be entirely different. All parts of the government responsible for aspects of national risk management should be reviewed or undertake internal exercises to learn from COVID-19.

 

  1. RECOMMENDATION 2:

Make improvements to the NSRA process so as to ensure that it captures all future risks. In particular:

 

●        Ensure the NSRA captures high-uncertainty risks, so as to close gaps in the process. This can be achieved by ensuring low-probability and emerging risks are included, by looking beyond the recent past, by using techniques such as red teaming and tabletop exercises, and by using a vulnerability based approach for the national risk assessment.

 

●        Improve how the NSRA categorises, compares and communicates risks, so that policy makers understand the risks. Consider moving from away from the use of reasonable worst case scenarios (for example move to pre- and post-mitigation worst case scenarios) and find additional ways to highlight and explain where there is high uncertainty.

 

●        Make greater use of external experts, so as to minimise the risk of blind spots and groupthink. For example, consider giving a mandate to review and provide feedback on the full NSRA to an independent body.

 

  1. RECOMMENDATION 3:

Establish a government Chief Risk Officer and associated unit, so as to both improve the available expertise in managing risks and uncertainty and to provide a governance structure for risk management. This unit would carry out depoliticised risk assessments, support departments in developing high-quality flexible risk plans, assign responsibility for acting on risks to ministers, and hold ministers to account for the quality of their department’s risk plans. This unit should have a degree of independence from Ministers.

 

Annex: An alternative approach to categorising risks from disease

 

This illustrates how, on the basis of information available in 2017, UK risk assessors could have better delineated disease risk in a manner that supports decision making by breaking it into three scenarios:

 

  1. A highly infectious effectively uncontainable disease with a low but not insignificant fatality rate. A RWCS could be modelled on the Spanish flu but should recognise that there could be uncontainable diseases that are not influenza.

 

  1. A somewhat infectious but still containable disease with a high fatality rate. A RWCS could be based on SARS or Ebola.

 

  1. A highly infectious, uncontainable disease with a high fatality rate. A RWCS could be based on a red teaming exercise with experts to develop scenarios.

 

To the best of our knowledge this final worst case scenario is plausible but has not been raised or prepared for. It is possible that this work is happening in secret.

 

 

References

 

[1] Centre for the Study of Existential Risk (2020). Risk management in the UK: What can we learn from COVID-19 and are we prepared for the next disaster?

[2] Cabinet Office (2017). National Risk Register Of Civil Emergencies

 

[3] Professor Neil Ferguson (2011). Question 82. House of Commons - Scientific advice and evidence in emergencies - Science and Technology Committee

 

[4] Department of Health (2011). UK Influenza Pandemic Preparedness Strategy 2011

 

[5] Cabinet Office (2019). National Security Risk Assessment (visible at: The Guardian (2020). What does the leaked report tell us about the UK's pandemic preparations?)

 

[6] Parliamentary Office of Science and Technology (2019). Evaluating UK natural hazards: the national risk assessment

 

[7] OECD (2017). National Risk Assessments: a Cross Country Perspective

 

[8] McCloskey, Dar, Zumla and Heymann (2014). Emerging infectious diseases and pandemic potential: status quo and reducing risk of global spread.

 

[9] Machalaba and Karesh (2017). Emerging infectious disease risk: shared drivers with environmental change.

 

[10] World Economic Forum (2016). The Global Risk Report 2016. This paper highlights that an emerging infectious SARS like disease could lead to tens of millions of fatalities. (p. 59)

 

[11] Global Challenges Foundation (2017).  Global Catastrophic Risks 2017. This paper highlights the risks of emerging infectious diseases that could kill tens or hundreds of millions including the scenario of a SARS type outbreak that is worse than the previous outbreak.

 

[12] Monaghan (2003). SARS: Down but still a threat - Learning from SARS

 

[13] Future of Humanity Institute (2008). Global Catastrophic Risks Survey. This survey of academic risk experts shows some degree of academic consensus on emerging infectious diseases as one of the largest threats.

 

[14] Institute for Government (2020). How fit were public services for coronavirus?

 

[15] Professor Van-Tam (2020) DQ1008 Oral evidence: UK Science, Research and Technology Capability and Influence in Global Disease Outbreaks

 

[16] The Guardian (2020). Experience of Sars a key factor in countries’ response to coronavirus

 

[17] Axios (2020). SARS made Hong Kong and Singapore ready for coronavirus

 

[18] Fortune (2020). SARS taught Taiwan how to contain the coronavirus outbreak

 

[19] This is based on reading through previous copies of the NRR at National Risk Register (NRR) of Civil Emergencies, and drawn from our conversations with civil servants.

 

[20] Centre for the Observation and Modelling of Earthquakes, Volcanoes and Tectonics (2016). Quantifying health and aviation hazards from Icelandic volcanic eruptions to inform government policy

 

[21] Thordarson and Self (2003). Atmospheric and environmental effects of the 1783–1784 Laki eruption: A review and reassessment

 

[22] Cabinet Office (2015). National Risk Register of Civil Emergencies chapter 2: risk summaries

 

[23] Cowling et al (1935). Aerosol transmission is an important mode of influenza A virus spread.

 

[24] Penn Medicine Physician Blog (2020). COVID-19: Droplet or Airborne Transmission? Penn Medicine Epidemiologists Issue Statement

 

[25] Comparing an approximate 1% fatality rate of Spanish Flu and an approximate 1% fatality rate of COVID as estimated by Imperial College London. Imperial News (2020) COVID-19 deaths: Infection fatality ratio is about 1% says new report

 

[26] This paper does not take a view on the effectiveness of lockdowns as a strategy for addressing pandemics, but simply states that they should have at least been identified as a possible option.

 

[27] Financial Times. (2020). Britain’s £5.5bn bill for procuring emergency PPE brings scrutiny

 

[28] Biosecurity Research Initiative at St Catharine’s College, Cambridge (2020). A solution scan of societal options to reduce SARS-CoV-2 transmission and spread. This solution scanning exercise, designed to inform policy makers on how to respond to COVID-19, is a good example of flexible risk planning in practice.

 

[29] Anonymous source (2020). Views provided directly to us during the research process.

 

[30] Department of Health (2014). Impact of Mass Gatherings on an Influenza Pandemic Scientific Evidence Base Review

 

[31] Institute for Government (2020). Decision making in a crisis

 

[32] The Guardian (2020). Two-thirds of public think UK coronavirus response too slow – poll

 

[33] Business Insider (2020). The UK's former chief scientific adviser says Boris Johnson's slow response to the coronavirus pandemic cost lives

 

 

(November 2020)